Student Application

General Information
Emergency Information

Background Information


Release of Liability

Release of Information


  1. I agree to the following requirements, with the understanding they may be required for my internship/clinical rotation/job shadow experience at Broadlawns Medical Center*:
    • Turberculosis (TB) skin test within last 4 years.
    • MMR tier or proof of immunization - 2 doses.
    • Physical exam within the last 4 years. Not required for job shadowing.
    • Criminal background check.
    • Wear school or student identification badge at all times during internship/clinical rotation/job shadow experience.
    *If you do not have one of these requirements, please contact Kari Ford at (515)282-2278 or Dianna Peterson at (515)282-2483.
  2. I understand my responsibility to be on time, attentive, courteous, and protective of patient confidentiality.
  3. I understand that in the performance of my duties as a student, I must hold in strictest confidence any observations I may make or hear regarding patients, patient families, clients, staff, or volunteers.
  4. I understand that intentional or involuntary violation of confidentiality may result in disciplinary action, including termination of my own internship/clinical rotation/job shadow experience and/or possible legal action by others (i.e. patients, patient families, clients, staff, etc.).